Provider Demographics
NPI:1417963133
Name:DE LA TORRE UGARTE, FERNANDO (MD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:
Last Name:DE LA TORRE UGARTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66508-1338
Mailing Address - Country:US
Mailing Address - Phone:785-562-2517
Mailing Address - Fax:785-562-5149
Practice Address - Street 1:1902 MAY ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66508-1200
Practice Address - Country:US
Practice Address - Phone:785-562-2517
Practice Address - Fax:785-562-5149
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24207208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025891000Medicaid
KS023499OtherBC/BS KS
NE20592OtherBC/BS NE
KS100135440AMedicaid
KS023499Medicare PIN
NE10025891000Medicaid